1. Case report n°2 Metabolic disorder A&E medical meeting 22/02/2012

2. Presentation: American male 63 years Past medical history: diabetes type 2 treated by Metformin 200mg x 2 Past surgical history: Colon cancer operated 1 year ago followed by chemiotherapy Current history: vomiting (2-3/day) and diarrhea (9/day) for 6 days, no fever.

3. Physical examination General status: asthenia ++, but normal consciousness, no neurodeficit General status: asthenia ++, but normal consciousness, no neurodeficit Cardio. exam:regular, no abnormal murmur, no sign of cardiac failure Cardio. exam:regular, no abnormal murmur, no sign of cardiac failure Pulmo. exam: clear, no rale, no evident dyspnea, no crackles at the bases Abdo. exam: soft, no local pain, no organomegaly, B.sound increasing +++ Dehydration +/- Legs: no edema.

7. Diagnosis hypothesis ? What kind of acido-basic disorder is-it? What is the origin of this acido-basic disorder? Which biologic test (or calculation) could you ask to have a more accurate analysis? What are the possible origins of this severe renal failure? What is in favor of acute/chronic renal failure?

8. Abdominal ultrasound The liver is normal in size. Its borders are regular. Its structure is hyperechoic. No focal lesion seen. The liver is normal in size. Its borders are regular. Its structure is hyperechoic. No focal lesion seen. The gallbladder is anechoic. Its wall is not thickened. The bile ducts are not dilated. The gallbladder is anechoic. Its wall is not thickened. The bile ducts are not dilated. Normal portal flow. Normal portal flow. The spleen, the pancreas demonstrate no abnormality. The spleen, the pancreas demonstrate no abnormality. The kidneys are normal in size (right=110x51x74mm, left = 120x52x57mm). No renal stone detected. No hydronephrosis noted. The kidneys are normal in size (right=110x51x74mm, left = 120x52x57mm). No renal stone detected. No hydronephrosis noted. Absence of ascites. No pleural effusion. Absence of ascites. No pleural effusion. No suspicious lymphadenopathy. No suspicious lymphadenopathy. The urinary bladder is anechoic with regular borders The prostate measures 35x48x35mm=30.5ml (normal < 30ml).

11. Renal failure analysis Creat about 600micmol/l > Clearence 16ml/min (Cokroft formula) Kidneys normal size No anemia (Hb 12.4g) No hypercalcemia (1.98mmol/l) Conclusion: Fonctional Acute Renal failure due to dehydration (vomiting & diarrhea) + Metformin treatment

12. Acido-basic disorder pH 7.24 with pCO 2 25mmHg & Bicar 11mmol/l Metabolic acidosis (Bicar ↓ & pCO2 ↓) Anion gap: The term anion gap represents the concentration of all the unmeasured anions in the plasma (ex: Lactates, ketonic, ethanol etc…) Anion Gap* = Na – (Cl + HCO3) * Normal 12 +/-2 mmol/l

13. Different kind of lactic acidosis

14. Anion gap calculation Anion Gap = Na –(Cl + HCO3) Anion Gap = 131 – (101 +11) = 19mmol/l Anion Gap slightly increased 19mmol/l (normal 12 +/-2mmol/l) Lactate dosage: 0.96mmol/l (normal 0.63 – 2.44mmol/l) This is not a lactic acidosis under Metformin…

15. Anion Gap increased Anion Gap normal

16. How to analyze a metabolic acidosis 1.Recognize the metabolic acidosis (pH<7.35 with HCO3 ↓) 2.Calculate the “Anion Gap” to know if this acidosis is due to accumulation of acid (Anion Gap increased) or a loss of base (Anion Gap normal) 3.Look for the origin of the disorder (see table before)

17. Evolution in ICU 6/02 (6h00) 6/02 (23h00) 7/2 (6h00) pH7.247.287.29 pCO2 (mmHg) 2525.530 Bicar (mmol/l) 1111.914.4 Base Excess -16-15-12 Creat (micmol) 598396311